Polycystic Ovary Syndrome - a TCM Perspective

by Donna Dupre, L.Ac. DAOM as seen at clinicalnature.com

Stein and Leventhal first described Polycystic Ovary Syndrome (PCOS) in 1935,¹ and much has been learned about PCOS since that time. PCOS affects 4% to 12% of women of reproductive age, and is associated with 75% of women suffering from infertility due to anovulation.² Due to the fact that there is such a wide range of symptoms associated with PCOS, getting a clear diagnosis can be confusing and treatment options can be daunting. This paper will look at the diagnosis and treatment of PCOS from both a Western Medical perspective and a TCM perspective. Studies have shown that TCM is effective in the treatment of PCOS and early diagnosis improves prognosis. Having an understanding of the Western Medical physiology and the ability to effectively translate the signs and symptoms into TCM diagnosis and treatment has shown to be very effective in treating PCOS.

From a Western Medical perspective there are a wide range of treatment options depending on presentation and individual health concerns of the patients. Some of the clinical features of PCOS include hirsutism, acne, male pattern alopecia, acanthosis nigricans (skin tags), oligomenorrhea, amenorrhea, anovulation, hyperandrogenism, infertility, and/or first trimester miscarriages. It is not understood how or why women develop PCOS, but it is thought to have a genetic predisposition. Although not all women with PCOS are obese, more recent understanding of PCOS has linked it to obesity and Insulin Resistance (IR). IR has many long-term serious health risks such as Type II Diabetes Mellitus, dyslipidemia, and cardiovascular disease. Due to the serious long-term health implications, early diagnosis and treatment of PCOS is important.

Western Medicine does not offer one specific diagnostic test nor is there one presenting symptom that would confirm a clinical diagnosis of PCOS. There are many conflicting criteria, which makes a diagnosis confusing. In addition to the unclear, conflicting diagnostic criteria, PCOS patients present with a wide range of signs and symptoms; and presentation is different for each patient. The most simplistic diagnostic criteria for PCOS is the presence of hyperandrogenism and/or chronic anovulation not caused by adrenal and/or pituitary disease. Clinically, hyperandrogenism can be diagnosed by a physical examination revealing the presence of excessive growth of coarse hair on women in places such as the chin, upper lip, abdomen, back or chest, and acne. The presence of acne can vary in degrees as can all the other signs and symptoms. Chronic anovulation is another hallmark sign of PCOS and is associated with oligomenorrhea and/or amenorrhea. Not all women with PCOS experience oligomenorrhea or amenorrhea and it sometimes occurs at different stages in their life. There is not one specific pattern and not everyone with PCOS presents in exactly the same way. Depending on the individual presentation and what is most distressing to the patient, PCOS patients could seek treatment from a number of different specialists including, but not limited to, a Dermatologist, Gynecologist, Endocrinologist, Reproductive Endocrinologist or Acupuncturist. As a health care practitioner, it is important to get a complete patient history, look for a pattern and not just focus on treating any one symptom. If a patient does present with two or more of the above symptoms, further examination, laboratory evaluations, and a pelvic ultrasound should be performed to either confirm a PCOS diagnosis or rule out other disorders which can present with the same symptoms. For instance, amenorrhea can be caused by pregnancy, hypothyroidism or hyperprolactinemia. Adrenal tumors and adrenal hyperplasia should also be ruled out as they have many of the same presenting signs and symptoms associated with elevated androgen levels.

A pelvic ultrasound can be helpful in the diagnosis of PCOS although not all women with polycystic ovaries have PCOS. Since more than 20% of women with polycystic ovaries do not have PCOS, it is important to evaluate the number of follicles and ovarian volume in making a diagnosis of PCOS. The current most cited ultrasonograpy criteria for PCOS is more than 10 cysts measuring 2-8 mm around or within a dense core of stroma. Jonard et al. has proposed modifying these criteria to: "increased ovarian area (>5.5cm2) or volume (>11 mL) and/or presence of >/=12 follicles measuring 2 to 9 mm in diameter (mean of both ovaries)."³ This newly proposed criterion has 99% specificity and 75% sensitivity for diagnosing PCOS. At present, the diagnosis criterion varies widely. For instance, the National Institute of Health does not include ultrasound as part of their diagnostic criteria; as opposed to Europe where the diagnosis criteria is based on ultrasound finding alone without any hormone testing. In an effort to make the diagnosis of PCOS less complicated it has been proposed by Homburg that when any one of the four most common PCOS symptoms are present (menstrual disturbance, hirstisum, acne or anovulatory infertility) a pelvic ultrasound should be performed. If polycystic ovaries are found, then a PCOS diagnosis can be confirmed. If the ultrasound does not reveal cysts on the ovaries then further laboratory testing should be performed to look for any one or more of the following to confirm a positive diagnosis: elevated LH, fasting glucose/insulin <4.5, and/or elevated testosterone or free androgen index.⁴

More recent understanding of PCOS has revealed the correlation with IR and hyperinsulinemia. IR and hyperinsulinemia are now understood to be directly correlated with annovulation and also predispose patients for Type II Diabetes Mellitus. The diagnostic criteria for IR in women is any three or more of the following presentations: waist circumference > 88 cm, triglycerides > 150 mg/dL, HDL cholesterol <50 mg/dl, blood pressure > 130/85, fasting glucose > 110.⁵

In the normal ovarian cycle one follicle continues to grow and mature, an egg is released during ovulation and the other less mature eggs experience atresia. The ovaries of a woman with PCOS do not produce a dominant mature egg that would be released at ovulation and the multiple follicles remain immature. This causes the pituitary to continue sending a signal to produce more LH to prepare for ovulation. It also inhibits the production of FSH and progesterone. The multiple immature follicles develop into cysts and continue to release LH, oestrogen, and testosterone, which inhibit the formation of a mature egg and the formation of the corpus luteum. In PCOS, the cycle is stalled halfway and the abnormal release of hormones creates hyperandrogenism and its associated signs of hirsutism and acne. The inability to produce a mature follicle results in anovulation and infertility in PCOS.⁶

Once a diagnosis is achieved, treatment options will depend on what the medical provider deems most crucial at that particular stage. "Generally there are but four issues which arise in the management of PCOS patients: regulation of menses, control of hirsutism, fertility issues, and the management of IR syndrome"⁷ and its complications.

From a Western Medical perspective there are many treatment options for PCOS. Treatment depends on the presenting symptoms and the health concerns of each patient. I will discuss the most common Western Medical treatments. Treatment can vary depending on fertility issues and severity of symptoms.

The most commonly prescribed treatment for PCOS in women who do not wish to become pregnant are oral contraceptives. Oral contraceptives can regulate the menses and lower testosterone levels. However, oral contraceptives can also raise triglyceride levels; therefore hypertriglyceridemia should be ruled out before they are prescribed. Progesterone therapy is another option to regulate the menses. Using progesterone for 7 - 10 days should stimulate a cycle within a week of stopping the progesterone.

Elevated testosterone and/or androgen levels cause hirsutism. Oral contraceptives, Metformin, and most importantly, lifestyle modification including weight loss can manage hirsutism. Spironolactone is the most commonly prescribed aldosterone antagonist, which suppresses testosterone levels and is used to manage hirsutism.

Metformin is used to improve insulin sensitivity and lower insulin levels, which directly affects anovulation and hyperandrogenism. Metformin can also reduce the risk of gestational diabetes and first trimester miscarriages; however, its safety during pregnancy is not yet known. Recently, Metformin has become the first line of treatment for PCOS; however, many patients experience side effects such as abdominal bloating, and severe diarrhea. If the side effects persist, then Metformin should be discontinued.

Anovulation infertility can be addressed in many different ways. Clomiphene is used to stimulate ovulation, however obese women do not respond favorably to this treatment. Clomiphene stimulates the production of FSH and blocks the action of oestrogen. The use of Clomiphene presents the risk of ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies. If Clomiphene does not stimulate ovulation within 6 months, then Metformin is often added; together they have shown positive results in stimulating ovulation.

Metformin and weight loss seem to have the most promising affect on improving IR, menstrual function and ovulation. Weight loss alone in obese patients with PCOS is shown to have a beneficial effect on all symptoms especially IR and its detrimental long-term health risks. The first line of treatment for any obese patient with PCOS should be weight loss. In fact, women with PCOS who are underweight tend to ovulate more frequently than women who are overweight or of normal weight.

Laparoscopic ovarian drilling by laser or diathermy and in-vitro fertilization are other treatment options for infertility caused by PCOS, but should not be considered as a first line of treatment and are usually considered after other treatment options have failed.

From a Chinese Medical perspective, it is always important to look at the individual presentation of each patient and not automatically put a disease or disorder into one generic pattern or diagnosis. All the signs, symptoms, tongue, and pulse need to be evaluated in making a diagnosis. That being said, it is common for a disease or disorder to fall into certain patterns of diagnosis in TCM. I will discuss the most common TCM diagnosis patterns for PCOS. Diagnosis and treatment will be specific to the individual presentation and modified accordingly as treatment progresses in this complex syndrome.

PCOS and its presenting symptoms of anovulation and infertility are most commonly caused by kidney deficiency. This can be kidney qi, yin or yang deficiency or a combination of these conditions. Since yin and yang are interdependent a deficiency of one can create a deficiency of the other. If the presentation were obesity with dampness and phlegm, which has suppressed ovulation, and a long cycle or amenorrhea, this would indicate a kidney qi and/or kidney yang deficiency with dampness and phlegm accumulation. Kidney qi and yang deficiency are often caused by or accompanied with a deficiency of spleen which fails to perform its function of transformation and transportation leading to damp and phlegm accumulation in the form of cysts on the ovaries. Other signs of kidney yang deficiency and damp phlegm accumulation include lethargy, cold limbs, frequent urination, heavy sensation in the abdomen, excessive vaginal discharge, a pale, swollen tongue with a sticky white coating, and a weak, slow, slippery pulse. There can also be blood stagnation associated with PCOS that would be indicated by abdominal pain and a purple or dusky tongue body. Cysts are usually fluid filled sacs that tend to be more damp phlegm, but sometimes can be chocolate cysts or blood filled cysts that are associated with blood stagnation. Amenorrhea and failure to shed the uterine lining each month can lead to qi and blood stagnation

The most common diagnosis for PCOS is kidney yang deficiency failing to transform with dampness and phlegm accumulation and possible qi and blood stagnation. Treatment principle is to tonify kidney qi, warm kidney yang, and transform dampness and phlegm, and if indicated, move qi and blood. Treatment can be modified to address what pattern is most prevalent and treatment should be adjusted as indicated by the patient's condition.

Acupuncture treatment:

• Lu 7 and Kid 6 - regulates conception vessels and dissipates masses
• Ren 3, St 28, UB32 - transform damp from genital system
• Sp 9, St 40 - resolve dampness and phlegm
• Kid 3, Ren 4, Kid 7, UB 23 with moxa - tonify kidney yang
• UB20, St 36 - tonify spleen and resolve dampness and phlegm
• UB 17, Sp10, St 29 - move blood stagnation ⁸
• Sp6 - tonify Spleen and kidney
• Zigongxue - stimulate ovulation

Herbal treatment:

Herbal formulas should be prescribed and modified as indicated by signs and symptoms. For instance if there is amenorrhea due to kidney yang deficiency then the formula needs to warm and tonify yang and stimulate the menses. Traditional herbal formulas can be prescribed such as Wen Jing Tang which contains herbs that warm yang, nourish blood, and move blood stasis. If the patient presents with pain due to qi and blood stagnation and a cold uterus as the most important issue, them formulas such as Gui Zhi Fu Ling Wan or Shao Fu Zhu Yu tang can be prescribed to move qi and blood, and warm and invigorate the menses. Cang Fu Dou Tan Tang is a traditional formula prescribed for PCOS when damp phlegm and qi and blood stagnation are the primary indications. Herbal treatments should be prescribed and modified as the condition warrants. TCM treatments should be fluid and modified as presentation changes from week to week.

A custom formula is generally more efficient in addressing a complex syndrome such as PCOS. The following herbal formula could be prescribed for kidney qi and yang deficiency with damp and phlegm, and qi and blood stagnation, and can be modified as needed:

• Gui Zhi - 9 g - warms and opens the channels, disperses damp cold and stagnation
• Fu Ling - 9 g - tonify spleen, drains damp
• Tu Si Zi - 12 g - tonify kidney yang, tonify spleen
• Du Zhong - 9 g - tonify kidney yang
• Xu Duan - 12 g - tonify kidney yang, move blood
• Fu Zi - 9 g - warm kidney yang
• Ban Xia - 7 g - transform phlegm, dry damp
• Bai Zhu - 9 g - tonify spleen, dry damp
• Wang Bu Liu Xing - 9 g - moves blood, moves stagnation in liver and inguinal area
• Qing Pi - 6g - Moves qi in the liver channel, dries damp and phlegm
• Ji Lin Ren Shen - 12 g - tonify qi kidney, spleen and lungs
• Bai Shao - 6 g - nourish yin and protects the blood and yin
• Gan Cao - 6 g - harmonize - reduce toxicity of Fu Zi

PCOS can also be caused by kidney qi and yin deficiency, which can be the result of long-term qi and blood deficiency or a constitutional deficiency. Patients with PCOS have a relative yin deficiency compared to high testosterone which is yang. When the kidney qi is deficient the function of transforming fluids is impaired which creates a damp and phlegm pattern. This also creates yin deficiency because the fluids are not being used to produce healthy yin and instead produce damp and phlegm in the form of cysts. Blood deficiency could also be a part of this pattern because healthy blood is not being produced due to the pathological transformation process that inhibits healthy blood production. When qi is deficient it looses its ability to transform and is unable to produce sufficient blood and jing. This creates blood deficiency and stagnations, which create a pathological cycle of jing being used up to create blood and our kidney energy, which is so important in fertility, becomes deficient. If the body cannot produce healthy kidney yin, it can lead to deficiency with an empty heat pattern; manifesting as hot flashes, night sweats, thirst, insomnia, and other associated signs and symptoms that can be a precursor to menopause. Kidney yin deficiency can be difficult to treat once it has progressed to a certain point and/or if the woman is of advanced age.

Acupuncture treatment:

• Ren 4 and Sp6 - nourish kidney yin
• Sp4 and PC6 - regulate and opens Chong vessel
• Lu 7 and Kid 6 - regulates conception dissipates masses
• Kid 13, Kid 3, UB23 - tonify kidney
• Kid 2 - clear deficiency heat
• Zingongxue - stimulate ovulation
• Sp 9 and St 40 - resolve dampness and phlegm
• St 36, UB20 - tonify spleen and resolve dampness and phlegm
• UB17, Sp10, St 29 - move blood stagnation

Herbal treatment:

Herbal formulas prescribed to treat kidney yin deficiency are Liu Wei Di Huang Wan or if there is a deficiency heat pattern, Zhi Bai Di Huang Wan, which can be modified with herbs to resolve dampness and phlegm and/or move qi and blood as indicated by presenting signs and symptoms. Again, a custom formula is more efficient and can be prescribed and modified as necessary. An example of a formula to nourish kidney yin, resolve dampness and phlegm, and move qi and blood stagnation is the following:

• Shan Yao - 15 g - tonify qi of kidney, spleen and lung, promotes fluid metabolism
• Ji Lin Ren Shen - 12 g - tonify qi of kidney, spleen and lung
• Bai Zhu - 9 g - tonify spleen, dry damp
• Ci Wu Jia - 12 g - tonify kidney and spleen qi
• Tu Si Zi - 9 g - tonify kidney yang and spleen qi
• Gou Qi Zi - 9 g - tonify jing, blood and yin
• Zhi Mu - 9 g - tonify kidney yin, clear deficiency heat in kidney
• He Shou Wu - 6 g - tonify blood and jing
• Ban Xia - 7 g - transforms phlegm, dry damp
• Fu Ling - 9 g - tonify spleen, drains damp
• Huang Jing - 6 g - tonify jing; tonify spleen and kidney
• Ji Nei Jin - 6 g - moves stagnation, secure essence, aids digestion
• Nu Zhen Zhi - 9 g - Tonify kidney and liver yin

There can be other TCM syndromes or contributing factors that can lead to PCOS such as long term liver qi stagnation, heart fire or yin deficiency brought on by stress, lifestyle, diet or constitution. Although the kidneys play an important role in ovulation, the spleen and its function of transformation and transportation is involved in the formation of cysts. TCM always looks at the body as a whole system and when one part of the whole is not functioning in a healthy, compatible, supportive way it affects the other organs. In general, kidney yang deficiency with damp and phlegm is the most common pattern of diagnosis for PCOS, and studies have shown it to be treated with greater success than kidney yin deficiency type with damp and phlegm. Chinese herbs have been shown to be more effective than Western Medicine in stimulating ovulation, which increases the likelihood of conception.⁹ In general, lifestyle changes, which include weight loss when necessary, and TCM treatment with herbs and acupuncture have proven to be very effective in the treatment of PCOS. The Huang Ling et al. study titled "Treatment of Polycystic Syndrome (PCOS)" found Chinese herbs to be 90.62% effective in treating Spleen and kidney yang deficiency pattern PCOS¹⁰, and hopefully further research on PCOS and TCM in the United States will be initiated to further validate its efficacy.

REFERENCES

1. Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management, Chinese Medical & research, 2003, 1:13-27
2. Homberg, Roy, The management of infertility associated with polycystic ovary syndrome, Reproductive Biology and Endocrinology, 2003, 1:109
3. Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management, Chinese Medical & Research, 2003, 1:13-27
4. Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management, Chinese Medical & Research, 2003, 1:13-27
5. Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management Chinese Medical & Research, 2003, 1:13-27
6. Lyttleton, Jane, Treatment of Infertility with Chinese Medicine, Churchill Livingston, 2004, p.188-189
7. Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management, Chinese Medical & Research, 2003, 1:13-27
8. Maciocia, Giovanni, Obstetric & Gynecology in Chinese Medicine, Churchill Livingston, 1998, p. 808-810
9. Lyttleton, Jane, Treatment of Infertility with Chinese Medicine, Churchill Livingston, 2004, p 208-221
10. Flaws, Bob, Dip. Ac. & C.H. Lic. Ac., FINAAOM, FRCHM, abstracted & translated, Hua Ling et al.'s Treatment of Polycystic Ovarian Syndrome (PCOS), Blue Poppy Press Research Report #404, Copyright Blue Poppy Press, 2003

BIBLIOGRAPHY

• Flaws, Bob, Dip. Ac. & C.H. Lic. Ac., FINAAOM, FRCHM, Abstracted & translated, Hua Ling et al's Treatment of Polycystic Ovarian Syndrome (PCOS), Blue Poppy Press Research Report #404, Copyright Blue Poppy Press, 2003
• Homberg, Roy, The management of infertility associated with polycystic ovary syndrome, Reproductive Biology and Endocrinology, 2003, 1:109
• Lyttleton, Jane, Treatment of Infertility with Chinese Medicine, Churchill Livingston, 2004, p.188-189 & p. 208-221
• Maciocia, Giovanni, Obstetric & Gynecology in Chinese Medicine, Churchill Livingston, 1998, p. 808-810
• Sheehan, Michael T., Polycystic Ovarian Syndrome: Diagnosis and Management, Chinese Medical & research, 2003, 1:13-27